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�:n <br /> �E��' �� ��"E��� <br /> � ��EF���� ��r��� �,�t��������� ���- fV����c�r�a�c� / �er�c������� s�:. ; <br /> (v�i�aov���, �ioa€��, siai��, ��-raof, ��c.) <br /> Narlrng Aadr�ess: Permit number: ��/ —b/ � <br /> ��'�v�.� PO Box o0 <br /> �� �, Q\ Crysial Bay, MN 55323-0066 �ate received; J//,>:/oZ� <br /> ��a ��jP:��'` Received b :_ <br /> �, , � E;� a. Srreet Address: Y <br /> ��'�� , �" '�s"�' ��� 2750 Keliey Parkway <br /> `.y�9��rv , Orono MN 55356 Pkansreviewree: <br /> ��sxo � <br /> ' To.al:Fee: �J�/ l c-� <br /> Main: 952-249-4600 =ax: 952-249-401 o www.ci.orono.mn.us I / (G�, J <br /> This appfication rorm must be comple'teo in rull and all required inforrration must be submitted. <br /> incompfete appficaiions will be returne�. (Please print) <br /> ���'=RAL INFORMp.TIOn: <br /> Job Site Acidress: �% ;� !��' C'L�U�•{,.1� � � <br /> Will tnis be a Parade of Homes, Remodeiers Showcase Home or other Dispday Fiome? I I yos �� �o <br /> lfyes, a special event permit is required wifn Foiice Deparrmenf and City Council approva!6G days prior to the event. Shuttle bus service wilf be <br /> required unless applicant demonstrates sufiicient on-site parking is availabte. Nor-permrtted events will not be alrowed. <br /> CON'i"'RACTOR//�PPLICAI�T INrOP.MAT10t�: <br /> Name: - <br /> State License # L�) '��J cxpiration Qate: (� (� <br /> Lead Certification Number, cxpiration Qate: <br /> (for work on �omes fhat were constructed prior ro 1978 <br /> Phone: � l �,- �,�'� �u�.(�, (ofiice) (cell) <br /> �aifing Address: �Lil"() �_� ' �OY' �, ��; � CitY��`�A�'� k� Zlp��j 5���� <br /> Contact Person: ����v.,,�� Apphcant is: Contractor / Homeowner (Gircfe One) <br /> Email and/or Fax: <br /> PROP�R�'Y OWN�R INrORMATIOht: � <br /> Name: _S�r^�v�c. �t: � Gi,�`� �� h <br /> Phone (�ay): '_C`,��M '� �� �a-���-03�� � ��. <br /> Address: '� �-� �.��,�,n�� � ., Ci"ty� ZIP� ;:� <br /> Email and/or Fax <br /> '� <br /> '� <br /> PRC2J�CT IN;ORM�t,TIOR: <br /> Type of Project: � � i Any earth movement rnay require �'� <br /> ❑ Door(s) � ❑ Remodel I MCWD review&permits: � <br /> ❑ �ire Camage �innehana Creel<Watershed District(MCWD) 5 <br />� .�e-roof, asphalt ❑ Repair I ❑ Storm Darrfage ! 15202 Ninneionica Bivo <br /> t ❑ Re-roof, ceuar ❑ Restoration ❑VIla'ter Gamage � Deeohaven, MN 55391 <br />� Phone: 952-471-Q590 <br />� ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (specify) � �ar.: 952-471-Oo62 <br />�� i ❑Window(s) I www.minnehahacreek orq � .� <br />,,�� � ; <br /> 1,� Overall Froject Descriptiars:'t-e�`i��j L�'�-U'-C3U�� ` <br /> ' _stirriated Cor.strucfion �,�aivanon a� ?ro�ect �exciucfing land) � 7�',C�b ;x <br /> � pPPLICA ^ R � �� — � <br /> � I�T ��E�f+�OVIA_�D.z�M�f�ET: ,� <br />� � Agrees to provide all inrormation required or requested by tne Building Department; ;� <br /> � � <br /> i! ` • Certifies t'nat the inrormaiion supp(ied is true and corre�t to the bes� or nis/ner knowledge. Tne applicant recogntzes that tney � <br /> are sofefy responsible fo�submitfing a compfete appiicaiion beina aware trat uoon �ailure to do so, tne s�aff h2s no atierrafive � <br /> � but io reject it until it is complete; _� <br /> t ` � <br /> � � Some or all of the informafion that you are asked to provide on tnis appfication is ciassified by Sta'te iaw as eitne~ private or � :� <br /> i coniidentiaf. Private da;a is inforrration wni�r� generally cannot be given to the pubiic but can be given to the subiect of ihe � iu <br /> , da:a. Confideniial data is inr"ormafion which generaliy cannot be give� io eifher the oubli� o; tnG suoiecf o� tne data. Our I <br /> � purpose and intended use of this informafion is tc annualf� update our recorcis and records o� otner governmen;al agen�ies I <br /> reauired bv lav,�. If vou reruse to sup�iv informaiion, the aopiicatior mav not b� issued. � <br /> � <br /> � l��/�/��- �: <br /> Appii�anYs Siqra'ture: � <br /> Cat�: <br /> L2st Updated: 08-Q9-201^ � � <br />